Standard versus distal Roux-en-Y gastric bypass in patients with BMI 50–60 kg/m2: 5-year outcomes of a double-blind, randomized clinical trial

Abstract

Background The optimal surgical weight loss procedure for patients with a BMI of 50 kg/m 2 or more is uncertain. This study compared distal Roux-en-Y gastric bypass (RYGB) with standard RYGB. Methods In this double-blind RCT, patients aged 18–60 years with a BMI of 50–60 kg/m 2 were allocated randomly to receive standard (150 cm alimentary, 50 cm biliopancreatic limb) or distal (150 cm common channel, 50 cm biliopancreatic limb) RYGB. The primary outcome (change in BMI at 2 years) has been reported previously. Secondary outcomes 5 years after surgery, such as weight loss, health-related quality of life, and nutritional outcomes are reported. Results Between May 2011 and April 2013, 123 patients were randomized, 113 received an intervention, and 92 attended 5-year follow-up. Mean age was 40 (95 per cent c.i. 38 to 41) years and 73 patients (65 per cent) were women; 57 underwent standard RYGB and 56 distal RYGB. BMI was reduced by 15.1 (95 per cent c.i. 13.9 to 16.2) kg/m 2 after standard and 15.7 (14.5 to 16.9) kg/m 2 after distal RYGB; the between-group difference was −0.64 (−2.3 to 1.0) kg/m 2 ( P = 0.447). Total cholesterol, low-density lipoprotein cholesterol, and haemoglobin A1c levels declined more after distal than after standard RYGB. High-density lipoprotein cholesterol levels increased more after standard RYGB. Vitamin A and vitamin D levels were lower after distal RYGB. Changes in bone mineral density, resting metabolic rate, and total energy intake were comparable. Conclusion Distal RYGB did not enable greater weight loss than standard RYGB. Differences in other outcomes favouring distal RYGB may not justify routine use of this procedure in patients with a BMI of 50–60 kg/m 2 . Registration number: NCT00821197 ( http://www.clinicaltrials.gov ). Presented in part as abstract to the IFSO (International Federation for the Surgery of Obesity and Metabolic disorders) conference, Madrid, Spain, August 2019.

Roux-en-Y gastric bypass limb lengths—how to optimize the balance between weight loss and risk of malnutrition?

“…The mid-term results of the double-blind DUCATI RCT (Dutch Common Channel Trial) 4 are contradictory, as Gadiot and colleagues reported a considerable and significantly increased weight loss after a very long RL gastric bypass (BP 60 cm, RL variable, CC 100 cm) compared with standard RYGB (BP 60 cm, RL 150 cm and CC variable). In concurrence with the Norwegian RCT 3 , they also reported a higher risk of overall complications after distal RYGB compared with standard RYGB (15.8 versus 9.0 per cent, P = 0.031).…”

“…One of the focuses in RYGB limb length studies has been the extended BPL length as the long BPL in biliopancreatic diversion (BPD) seems to be one of the key factors explaining the superiority of BPD for weight loss and remission of co-morbidities, but it also carries the potential for severe malnutrition 2 . In this issue of BJS Open, Salte and colleagues 3 show that in patients with BMI exceeding 50 kg/m 2 , distal RYGB with a short CC of 150 cm did not enable greater weight loss than standard RYGB at 5-year follow-up with a good long-term follow-up rate of 81 per cent (92 of 113 patients). In this double-blind randomized clinical trial (RCT), the finding of increased side effects after distal RYGB with no weight-loss benefit underlines the conclusion of the authors of not recommending distal RYGB.…”

Prevalence and associated factors of vitamin D deficiency after Roux-en-Y gastric bypass: a systematic review and meta-analysis

“… 63 arrived at similar findings by making a comparison between the standard RYGB and the distal RYGB. In our study, only two trials reported the distal RYGB with the 150 cm common channel 18 , 63 , and our results showed that the estimate of the postoperative VDD prevalence was 35% ( I 2 =0). Unfortunately, we could not identify distal RYGB as a potential factor for VDD (β=−0.054, P =0.748).…”

“…These included 12 cross-sectional studies, 21 prospective cohort studies, 27 retrospective cohort studies, and 2 randomized controlled trials. Out of these 62 studies, 10 contained two study groups that were analyzed separately 14 , 17 , 18 , 29 , 31 , 38 , 48 , 62 , 63 , 65 . Therefore, a total of 72 studies were included in the final meta-analysis (Supplementary Figure 1, Supplemental Digital Content 4, http://links.lww.com/JS9/B34 ).…”

“…Seven included studies compared the prevalence of VDD between the long Roux limb and the short Roux limb after RYGB 16 – 18 , 31 , 49 , 62 , 63 . The random-effects model showed no significant differences in prevalence between both groups (OR=1.35, 95% CI: 0.91–2.00, P =0.133).…”